Feedback systems and methods to enhance obstructive and other obesity treatments, optionally using multiple sensors

ABSTRACT

Feedback systems and methods enhance obstructive and other obesity treatments by presenting feedback regarding patients&#39; actual eating. An ingestion restricting implant body can be deployed along the gastrointestinal tract. In some embodiments, ingestion alters the implant body, which, in turn, generates signals. The generated signals can be used to inhibit unhealthy ingestion by the patient. In other embodiments, the implant body can be altered by signals so as to selectable change the restriction imposed on the gastrointestinal tract, optionally in response to ingestion events, an eating schedule, or the like. The implant body may comprise a gastric band. Sensor signals may be processed to identify ingestion and/or characterize ingestion material, and the results may be displayed on a screen for a patient or coach to view.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application claims the benefit under 35 USC 119(e) of U.S.application Ser. No. 13/250,757 filed Sep. 30, 2011, now issued as U.S.Pat. No. ______, entitled “Feedback Systems and Methods to EnhanceObstructive and Other Obesity Treatments, Optionally Using MultipleSensors” (Attorney Docket No. 90775-822276 (001910US) and alsoProvisional Application No. 61/388,900 filed Oct. 1, 2010, entitled“Feedback Systems and Methods to Enhance Obstructive and Other ObesityTreatments” (Attorney Docket No. 90775-793093, formerly026458-001900US); the full disclosures of which are incorporated hereinby reference in their entirety. The subject matter of the presentapplication is related to that of Application No. 61/166,636 filed Apr.3, 2009, entitled “Feedback Systems and Methods for CommunicatingDiagnostic and/or Treatment Signals to Enhance Obesity Treatments”(Attorney Docket No. 90775-759447, formerly 026458-001200US); U.S.application Ser. No. 12/145,430 filed Jun. 24, 2008, entitled “SensorDriven Gastric Stimulation for Patient Management” (Attorney Docket No.90775-751587 (formerly 026458-000610US); U.S. application Ser. No.10/950,345 filed Sep. 23, 2004, entitled Responsive Gastric Stimulator”(Attorney Docket No. 90775-714308 (formerly 026458-000141US); U.S.Application No. 61/122,315 filed Dec. 12, 2008, entitled “Detection ofFood or Drink Consumption in Order to Control Therapy or ProvideDiagnostics” (Attorney Docket No. 90775-759446 (formerly026458-001100US); U.S. application Ser. No. 12/637,452 filed Dec. 14,2009, entitled “Detection of Food or Drink Consumption In Order toControl Therapy or Provide Diagnostics” (Attorney Docket No.90775-779379 (formerly 026458-00111US), and U.S. application Ser. Nos.12/754,435 and 12/754,439, both filed Apr. 5, 2010 and entitled“Feedback Systems and Methods for Communicating Diagnostic and/orTreatment Signals to Enhance Obesity Treatments,” and “Feedback Systemsand Methods to Enhance Obstructive and Other Obesity Treatments”(Attorney Docket Nos. 90775-784709, formerly 026458-001210US and90775-784568, formerly 026458-001220US), respectively the fulldisclosures of each of which are also incorporated herein by referencein their entirety.

BACKGROUND OF THE INVENTION

Since the mid-seventies, the prevalence of obesity has increased sharplyfor both adults and children. These increasing rates raise concernbecause of their implications for Americans' health. Being overweight orobese may increase the risk of many diseases and health conditions,including: hypertension, dyslipidemia (for example, high totalcholesterol or high levels of triglycerides), type 2 diabetes, coronaryheart disease, stroke, gallbladder disease, osteoarthritis, sleep apneaand respiratory problems, and some cancers (such as endometrial, breast,and colon).

Obesity and its associated health problems have a significant economicimpact on the U.S. health care system. Medical costs associated withexcess weight and obesity may involve direct and indirect costs. Directmedical costs may include preventive, diagnostic, and treatment servicesrelated to obesity. Indirect costs relate to morbidity and mortalitycosts. Morbidity costs are defined as the value of income lost fromdecreased productivity, restricted activity, absenteeism, and bed days.Mortality costs are the value of future income lost by premature death.

Many therapies are currently being investigated for treatment of obesityand diseases associated with obesity. To date, the widely used obesitytreatments have not been shown to be ideal, particularly for thoseafflicted with severe obesity. The approaches that have been proposedrange from lifestyle coaching to major surgical therapies.

Many severely obese patients have turned to surgical options. Thesesurgical options include highly invasive procedures such as stomachreduction and gastric bypass, while less invasive procedures include theimplantation of gastric bands. Another option for the severely obesepatients involves the endoscopic placement of an intragastric balloon, asilicon balloon device that is placed in the stomach endoscopically.

Unfortunately, patient compliance and the accuracy with which patientsreport their own activities can significantly limit the effectiveness ofweight loss treatments. One of the problems associated with the surgicalprocedures of gastric reduction, gastric bypass, gastric banding andintragastric balloons revolves around patient compliance. Even afterthese surgeries or endoscopic procedures, a number of patients find waysto “cheat;” they avoid the volume limitation imposed by stomachreduction from the above-mentioned procedures simply by ingestingliquids or liquefied solids that easily drain into their smallintestines. For weight loss treatment to be successful, the surgical orendoscopic procedures should ideally be combined with lifestyle changes.Patients' self-reporting has very often proven to be inaccurate.

Therefore, it would be desirable to provide devices, systems and methodsthat can accurately monitor and report a patient's actual daily caloricintake as well as activity related caloric expenditure, to be used inobesity treatment therapy. Ideally, such a system would provide apatient, his or her physician, a lifestyle coach, support group, and/orother caregivers the information collected about the patient's eatingand exercise habits for use in monitoring the patient's progress and soas to present actual behavior-based information to the patient foreffective behavior modification and greater success in achieving weightloss or health goals.

BRIEF SUMMARY OF THE INVENTION

The present invention relates to feedback systems and methods to enhanceobstructive and other obesity treatments. Although embodiments of theinvention make specific reference to treatment of obesity, the systemand methods described herein may be applicable to other treatmentsseeking patient behavior modification, and particularly disorders inwhich presenting feedback regarding patients' actual eating and/orexercise habits is desired.

In a first aspect, the invention provides a therapeutic implant systemfor treating a patient. The patient will typically have agastrointestinal tract and an unhealthy ingestion pattern. Thetherapeutic implant system will comprise an ingestion restrictingimplant body deployable along the gastrointestinal tract so as toseparate the gastrointestinal tract into a restricted portion of thegastrointestinal tract and a gastric pouch portion of thegastrointestinal tract upstream of the restricted portion. The implantbody will include a gastric band defining a channel therethrough, thegastrointestinal tract extendable through the channel of the implantbody, wherein the gastric band comprises a fluid-filled pressure bladderdisposed between the channel and a support structure such that changesin a fluid pressure within the fluid pressure bladder correspond withchanges in an engagement force between the gastrointestinal tract andthe gastric band. A sensor will be coupleable to the gastric pouchportion of the gastrointestinal pouch so that signals are generated inresponse to transient changes in the gastric pouch and the signalsindicate an ingestion event. A processor will be coupled to the signalgenerator and the implant body such that, in response to the signals,the unhealthy ingestion pattern by the patient is inhibited in usesufficiently to modify the unhealthy ingestion pattern toward ahealthier ingestion pattern.

In many embodiments, a display will be coupled to the processor. Thedisplay can show eating events identified in response to the signalsduring a plurality of days. The display can be configured forcommunicating to the patient and/or a lifestyle coach of the patient. Anactuator may be coupled to the processor so as to alter the fluidpressure within the bladder in response to the ingestion event. In someembodiments, at least two electrodes will be coupled to the processor soas to stimulate tissue of the gastrointestinal tract in response to theingestion event. In exemplary embodiments, at least one of a pressuresensor, a temperature sensor, an optical sensor, an impedance sensor, apH sensor, or an acoustic sensor will be coupled to the processor. Theoptical sensor may include a visible color sensor and/or an infraredlight sensor.

Some of the sensor signals can be transmitted from the bladder to theprocessor, and the altering of the engagement force may be induced by anactuator so that the pressure within the bladder is decreased each dayto allow healthy ingestion and increased each day to inhibit unhealthyingestion. Energizing the actuator may optionally activate the gastricband so as to increase restriction and decrease ingestion into thepatient. In other embodiments, energizing the actuator deactivates thegastric band so as to decrease restriction and allow increased ingestioninto the patient.

The sensor may be included in a transgastric probe having a probe bodywith a transgastric wall traversing portion. The sensor can be separatedalong the probe body from the wall traversing portion so as to bedisposed within an interior of the transgastric pouch. The transgastricprobe may include two or more members selected from the group consistingof a temperature sensor, an electrode, and a visible color sensor and/oran infrared light detector.

Two or more electrodes may be coupled to the processor, optionally so asto deliver electrical stimulation to the gastrointestinal tract and/oranother internal organ. The electrodes may be used as sensors, and/ormay be mounted along the channel of the implant body or on atransgastric probe body or both. Two sensors may be coupled to theprocessor and used to generate signals, and the processor may beconfigured to process the signals so as to identify transient changes inthe gastric pouch portion of the gastrointestinal tract.

In some embodiments, a temperature sensor can be coupled to theprocessor so as to provide a temperature from within the gastric pouchportion of the gastrointestinal tract. Optionally, the sensor maycomprise a visible color sensor and/or an infrared light detector.

In another aspect, the invention provides a system for treating apatient having a gastrointestinal tract. The system comprises aningestion restricting implant body deployable along the gastrointestinaltract. At least two sensors transmit signals in response to ingestioninto the patient in use. A processor is coupled to the at least twosensors. The processor, in response to the signals, generates ingestiondisplay signals or patient treatment signals or both.

In another aspect, the invention provides a therapeutic implant systemfor treating a patient having a gastrointestinal tract and an unhealthyingestion pattern. The therapeutic implant system comprises an ingestionrestricting implant body implantable along the gastrointestinal tract soas to separate the gastrointestinal tract into a restricted portion ofthe gastrointestinal tract and gastric pouch portion of thegastrointestinal tract upstream of the restricted portion. A sensor isconfigured to engage the gastric pouch portion, and a processor iscoupleable to the sensor so as to transmit signals therebetween. Thesignals are transmitted in correlation with transient changes in thegastric pouch portion of the gastrointestinal tract in use.

The implant body may have a first configuration and a secondconfiguration, the size, compliance, or shape of the implant body in thesecond configuration being different than the size, compliance, or shapeof the implant body in the first configuration such that the implantbody has an enhanced inhibition of ingestion in the secondconfiguration.

In another aspect, the invention provides a therapeutic implant fortreating a patient having a gastrointestinal tract and an unhealthyingestion pattern. The therapeutic implant comprises an ingestionrestricting implant body implantable along the gastrointestinal tract,and at least two sensors for generating signals. A processor is coupledto the at least two sensors and the implant body so as to transmit thesignals therebetween. The signals will be transmitted in correlationwith an ingestion event.

In yet another aspect, the invention provides a method for treating apatient having a gastrointestinal tract. The method comprises deployingat least a portion of an implant along the gastrointestinal tract. Theimplant has a body, at least three sensors and a processor. During aday, and in response to signals sent from the sensors to the processor,a candidate characterization of an ingested material is identified. Itis determined whether the ingested material constitutes an allowedingestion in response to the candidate characterization, and if so, theingested material is allowed to traverse the body of the implant alongthe gastrointestinal tract. It is also determined whether the ingestedmaterial constitutes an unhealthy ingestion in response to the candidatecharacterization, and if so, signals are transmitted from the processorto the body so as to alter a shape, compliance, and/or size of the bodysuch that the body restricts the unhealthy ingestion.

In a final aspect, the invention provides transgastric probe comprisinga probe body having a transgastric wall traversing portion and a gastriccavity portion. The gastric wall traversing portion is configured forextending through a gastric wall of a gastrointestinal tract of apatient so as to support the gastric cavity portion within a gastriccavity. A plurality of sensors are mounted to the probe body. At leastone of the sensors is disposed along the gastric cavity portion of theprobe body so as to be disposed within an interior of the gastric cavitywhen the probe body is implanted. The sensors include two or moremembers selected from the group consisting of a temperature sensor, anelectrode, and a visible color sensor and/or an infrared light detector.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows an exemplary system 100 suitable for implementation ofembodiments of the present invention.

FIG. 1A shows an exemplary gastric band sensor system implant 900 foruse in the system of FIG. 1.

FIG. 1B-1D illustrate the electrical stimulation component of thegastric band sensor system implant 900.

FIGS. 2A-2C illustrate alternative embodiments of system 900.

FIG. 2D shows an embodiment of system 900 comprising two pressuresensors 928 coupled to the fluid-filled cuff 903.

FIG. 2E shows an alternative embodiment of system 900 comprising atleast two lap bands, each lap band comprising at least one sensor 926.

FIG. 2F shows an alternative embodiment of system 900 comprising atleast one sensor extending through a wall of the gastric pouch and atleast two electrodes placed inside a lap band to provide electricalstimulation to the portion of the stomach in contact with the lap bandand/or sense gastric impedance.

FIG. 2G shows a multifunctional transgastric probe comprising integraltemperature and impedance sensors and a return electrode.

FIGS. 2G1-2G3 show alternative embodiments of the multifunctionaltransgastric probe.

FIGS. 2H and 2H1 show an alternative embodiment of the multifunctionaltransgastric probe which also comprises a color sensor at the distal endof the probe.

FIG. 2I shows a schematic configuration of a color sensor in amultifunctional transgastric probe when the gastric pouch is largelyempty; the color intensities measured by the photodiodes reflect thecolor of the gastric pouch cavity.

FIG. 2J shows a schematic configuration with a color sensor responsewhen the gastric pouch cavity includes a translucent material such ascoffee or a dark-colored soda.

FIG. 2K shows a schematic configuration with a color sensor response ina case after ingestion of a largely opaque meal in the gastric pouchcavity.

FIG. 3 illustrates ingestion of food or drink into a stomach.

FIG. 3A shows a cross-sectional view of the superior portion of thestomach constricted by a lap band 902 with a fluid filled cuff 903.

FIGS. 4A-4C show the pressure waveforms from pressure sensor signals onemight expect with food or drink input. More specifically, FIG. 4A showsthe expected pressure waveforms from an ingestion of food 1000. FIG. 4Billustrates an overeating event. FIG. 4C shows the expected pressurewaveforms 1200 from a drinking event.

FIG. 5 shows the pressure waveforms 1300 that occur with injection offluid, e.g. saline, into the port of the lap band.

FIG. 6 shows pressure waveforms from peristaltic waves 1400.

FIG. 7 shows an exemplary intragastric balloon-sensor-monitor system1500.

FIG. 8 shows a method of treating a patient with an unhealthy ingestionpattern 2000.

Fig.8A-8E show alternative treatments method comprising the therapeuticimplant.

FIG. 9 schematically shows a system and method for classification ofingestion events based on signals from a pressure and a temperaturesensor.

FIG. 9A shows an algorithm for determining the type of meal ingested andits duration based on signals from a pressure and a temperature sensor.

FIG. 10 shows an alternative treatment method comprising the therapeuticimplant and the multifunctional transgastric probe.

DETAILED DESCRIPTION OF THE INVENTION

The present invention often takes advantage of processors to enhanceobesity therapies that rely on restrictive implants disposed along thegastrointestinal tract. Some embodiments of the present invention relateto feedback systems and methods for communicating implanted sensor-basedinformation so as to affect behavior modification for eating disorders.Some embodiments of the present invention employ systems which alter arestrictive implant in response to signals. Although embodiments of theinvention make specific reference to treatment for obesity, the systemand methods described herein may be applicable to any treatment in whichpresenting feedback regarding patients' eating and/or exercise habits isdesired.

Embodiments of the present invention collect information regarding thepatient's eating and exercise habits via one or more sensors implantedwithin the body of the patient. This information can then be reviewed bya clinician during office visits and used in coaching the patient.Coaching may include helping the patient to make healthy lifestylechoices, such as specifically encouraging the patient to decrease his orher caloric intake while increasing his or her caloric expenditure.Compliance with physician advice may be low in obese patients andcaloric intake is often under-reported while caloric expenditures areoften over-reported. Although eventually weight gain or loss by apatient will indicate the accuracy of the patient's reporting, theobjective monitoring systems provided herein will significantly improvemany patients' ability to acknowledge their actual behavior, to identifyelements of their behavior that can be changed to improve health, and toeffect incremental changes toward achieving long-term health goals. Theimplantable sensors will often detect eating events, solid versus liquidintake, and optionally even meal compositions. The various implantablesensors can be implanted at the same time as the surgical procedures soas to minimize the number of surgical or endoscopic interventions in thepatients. The systems and methods described herein may identify eatingand other behaviors which the patient is not aware of (includingnight-time eating and the like). These systems and methods may alsoimprove the correlation between positive patient behavior and beneficialpositive reinforcement, and decrease deleterious correlations betweennegative patient behavior (such as under-reporting of actual ingestion,over-reporting activity levels, and the like) with misguided positivereinforcement. Such improvements may be particularly effective atpromoting and/or maintaining healthy activities when ultimate healthgoals remain distant.

The sensor and feedback system of the present invention is not subjectto the reporting bias of the patient, thus presenting an objective view.In addition, embodiments of the present invention allow data to becollected twenty-four hours per day, seven days per week, which providesan accurate record of the patient's behavior without dependence upon thepatient's memory or commitment to the eating and exercise trackingprocess. Some embodiments may sense and/or restrict caloric intake, suchas using a band implanted around the stomach so as to constrict flowalong the gastrointestinal tract, a gastric balloon inflated within thestomach, or the like. In still other embodiments, the present inventionalso provides stimulation of the stomach to reduce caloric intake.

Embodiments of the invention provide a system that stores the datacollected by the implanted system remotely. The system is then madeaccessible by the patients and/or the patients' health coaches tosupport the patient in achieving their weight reduction goals. Theautomated availability of behavior modification feedback, shortened timebetween “coaching sessions” and increased accuracy of the sensor datawill improve outcomes for the patients.

In some embodiments, the invention may employ aspects of socialnetworking systems, with sensor-based information that has beengenerated using signals from an implanted sensor often being availableto one or more members of a group. The group may, at least in part, bedefined by the patient giving permission to particular individuals.Other members of the group (such as the patient and a supervisingphysician) may be defined when the group is first organized. Manypatients having implanted sensors may join a mutual support group ofpatients, with sensor-based data being shared between the implantrecipients. Advantageously, these systems may allow patients to receivefeedback within a relatively short time after exhibiting behavior thatis sensed by the sensor, preferably within two days of the sensoridentifying an eating event or activity level, and ideally within oneday of the behavior. Using telemetry-based communication between theimplanted device and a home monitor (or other intermediate device), someembodiments may allow daily uploads, and/or send messages to a cellphone/Smart phone or personal digital assistant (PDA) in near real time.This significant shortening of the time delay between patient behaviorand relationship-based feedback to the patient may provide significantadvantages over feedback provided through monthly, quarterly, or annualappointments with a dietician or physician. Nonetheless, communicationenhancement described herein may provide efficacy benefits foralternative embodiments that rely on uploading of patient data duringsuch routine appointments.

To facilitate the relationships employed for implant patient feedback,embodiments of the invention may make use of aspects of Web-2.0 systemssuch as Facebook™ social networking systems and methods, MySpace™ socialnetworking systems and methods, Linked In™ social networking systems andmethods, or the like. Embodiments may also employ aspects of knownweight reduction support group systems and methods, particularly thosethat are enhanced through electronic telecommunications such as theWeightWatchers.com™ weight management portal, TheDailyPlate.com™nutrition and weight management system, and the like. The sensor datasharing aspects of many embodiments may employ systems somewhatanalogous to (and/or may be modified from) web-enabled athletic trainingcommunity systems such as those of TrainingPeaks.com™,EnduranceNation.us™. Still further aspects of the invention may befacilitated by systems and methods that have been developed (and arecontinuing to be developed, and/or will be developed in the future) insupport of Health 2.0 concepts. Hence, embodiments of the inventionsdescribed herein may leverage or be modified from a variety of knowntechnologies, including by employing Elgg tools and solutions forcreation of online communities as available at http://elgg.org.

An example system 100 suitable for implementation of embodiments of thepresent invention is illustrated in FIG. 1. In the embodiment shown, thesystem 100 comprises an implanted device 110 that communicates with ahome monitor 120 via a wireless transmitter 112, such as an RF telemetrymodule. The implanted device 110 includes at least one sensor 114 and,optionally, stimulation circuitry 116 for providing therapeuticstimulation to the patient. A server 130 communicates with home monitor120 via an internet or other telecommunication system so as to allowaccess to sensor-based data via a portal 150 and/or health coachworkstation 160, thereby providing sensor-based feedback to a patient140 (through direct presentation of the sensor-based information to thepatient, and/or through a health-coach/patient relationship).

Each of implanted device 110, home monitor 120, server 130, health coachworkstation 160, and a portable patient device will typically includeassociated data processing systems, with the overall feedback system 100combining their data manipulation and communication capabilities into anoverall data architecture. Generally, the data processing systemsincluded in the discreet devices of the invention may include at leastone processor. For implantable device 110, this will typically includecircuitry implanted in the patient. Other devices of system 100 willinclude circuitry external of the patient. Such external processorcircuitry may include one or more proprietary processor boards, and/ormay make use of a general purpose desktop computer, notebook computer,handheld computer, Smart phone, or the like. The external processor maycommunicate with a number of peripheral devices (and/or otherprocessors) and these peripheral devices may include a data and/orprogramming storage subsystem or memory. The peripheral devices may alsoinclude one or more user interface input devices, user interface outputdevices, and a network interface subsystem to provide an interface withother processing systems and networks such as the Internet, an intranet,an and/or the like. Implanted circuitry of the processor system may havesome of the constituent components described above for the externalcircuitry as well being coupled to an implanted battery or other powersource, with the implanted circuitry generally employing processors,data and software storage, and wireless communication capabilities(although hard-wired embodiments or other transcutaneous datatransmission techniques could also be employed).

Both external and implanted memory of the devices of system 100 willoften be used to store, in a tangible storage media, machine readableinstructions or programming in the form of a computer executable codeembodying one or more of the methods described herein. The memory mayalso similarly store data for implementing one or more of these methods.The memory may, for example, include a random access memory (RAM) forstorage of instructions and data during program execution, and/or a readonly memory (ROM) in which fixed instructions are stored. Persistent(non-volatile) storage may be provided, and/or the memory may include ahard disk drive, a compact digital read only memory (CD-ROM) drive, anoptical drive, DVD, CD-R, CD-RW, fixed or removable flash memory, memorysticks, solid-state removable memory, and/or other fixed or removablemedia cartridges or disks. Some or all of the stored programming codemay be altered after implantation and/or initial use of the device toalter functionality of the system.

The functions and methods described herein may be implemented with awide variety of hardware, software, firmware, and/or the like. In manyembodiments, the various functions will be implemented by modules, witheach module comprising data processing hardware and associated softwareconfigured to perform the desired function. The modules may be largelyintegrated together so that a single processor board runs a singleintegrated code for each device, but will often be separated so that,for example, more than one processor board or chip or a seriessubroutines or codes are used. Similarly, a single functional module maybe separated into separate subroutines or be run in part on separateprocessor chip that is integrated with another module. Hence, a widevariety of centralized or distributed data processing architecturesand/or program code architectures may be employed within differentembodiments.

The electronic circuitry of the various devices of system 100communicates via RF wired or wireless networking, and/or viatelecommunications linkages for coordinating the presentation ofsensor-based feedback from implanted device 110 to patient 140, as wellas to monitor and facilitate the various operations of the devices,including sensing, stimulating, signal transmission, charging and/orusing energy from a battery device for powering the various devices, andthe like. In some embodiments, the electronic circuitry of one or moreof the devices includes an internal clock. The internal clock may alsoinclude a real time clock component. The internal clock and/or real timeclock may be used to control stimulation, e.g., by stimulating orallowing stimulation at a particular time of the day. The real timeclock component may also provide a date/time stamp for detected eventsthat are stored as information in a memory device, includingsensor-based events, patient presentation events (such as accessingportal 150, receiving a text message, communicating with a health coachor group member, or the like). Optionally, the memory may be preservedby saving information corresponding to an event of interest which issaved along with the time/date when the event occurred.

Sensor 114 is coupled to at least one part of the gastrointestinalsystem, such as the gastric pouch or the stomach, so as to generatesignals responsive to ingestion, with the sensor ideally comprising atleast one temperature sensor for sensing temperature information fromwithin the stomach. The sensors may be located on or extend from ahousing of implanted device 110 and/or the sensors may be located on orextend from a lead or other device. Alternatively, sensor 114 may beincluded as part of a multifunctional transgastric probe 2000. FIG. 2Gshows a multifunctional transgastric probe 2000 comprising integraltemperature sensor 2002 and impedance sensor electrodes 2004 a and 2004b and a return electrode 2006. The transgastric probe 2000 has an outersurface comprised of a series of bands of isolated electricallyconducting surfaces 2008 alternating with electrical insulators 2010.Examples of conductive materials include metals, metal alloys, andcombinations of these and similar materials. Examples of such materialsinclude MP35N, steel, stainless steel, titanium, platinum and platinumiridium or other similar materials. Examples of electrically insulatingmaterials comprise silicon dioxide, silicone rubber, PEEK, Kynar, andTeflon. Both the conductive and insulating materials are chosen to bebiocompatible and withstand the corrosive environment of thegastrointestinal system, in particular the stomach. The multifunctionaltransgastric probe 2000 protrudes through the stomach wall 2007 into theinterior of the stomach. The electrically conducting surfaces 2008 ofthe probe 2000 are in direct contact with stomach contents 2005. Theseconducting electrode surfaces are subsequently connected to anelectrical impedance spectrometer (not shown) or an excitor circuit thatproduces low amplitude (<1 mA peak) current pulses (<100 msduration)-via conductive wires 2004 c and 2004 d respectively. Theelectrical signals generated at these isolated electrodes can then beused to perform subsequent analysis of the material(s) in contact withthem 2005. For example, the impedance data can give information as tothe electrical conductivity and pH, as well as other characteristics toenable identification of the ingested material 2005. The transgastricprobe 2000 includes a temperature sensor 2002 for sensing thetemperature in the immediate area of (and/or within an interior of) thegastric pouch or stomach. The return electrode 2006 function facilitateselectrical stimulation, sensing, and the like, and may also beconfigured so that the returning stimulation current may have highercurrent density than other return electrode structures. In thisembodiment the area of the return electrode in direct contact with thestomach is approximately 28 mm². This configuration may produce moreconsistent lead impedance measurements since the gastric pouch contentsare less likely to alter the measurements. In the cases where thisembodiment is used on a stomach wall, the stimulation current may alsobe more likely to flow on the exterior of the stomach wall.

FIG. 2G1 shows an alternative embodiment of the multifunctionaltransgastric probe. The multifunctional transgastric probe may beconstructed from concentric cylinders of alternating conducting(metallic) and insulating (e.g., plastic, ceramic) stomach-acidresistant materials. In this embodiment only two materials need beexposed to the internal stomach environment. Advantageously, theconcentric design permits relatively large areas of contact betweencylinders to facilitate sealing. Sealing can be accomplished withadhesive and/or thermal expansion/contraction. All electricalconnections are made internal to the electrode assembly and can bereadily accessed during assembly. The impedance electrode can share anelectrical wire with the temperature sensor/thermistor, reducingwire-count if desired. Weak impedance-measurement excitation currentlargely follows electric field lines. Desirably an insulating cap 2009will keep the opposing wall of stomach from shunting the impedancecurrent.

FIGS. 2G2 and 2G3 show further alternative embodiments of themultifunctional transgastric probe concentric cylinders of alternatingconducting (metallic) and insulating (e.g., plastic, ceramic)stomach-acid resistant materials.

Typically the lead body is comprised of an elongate structure havingconductive wires passing therethrough or therealong to couple thevarious sensors and electrodes disposed along the lead to the connectors(not shown) and then to the stimulation circuitry 116. In someembodiments, the lead body 2014 is comprised of an extruded polymerhaving one or more lumens, typically wherein each conductive wire passesthrough a separate lumen. Thus, the conductive wires are insulated fromeach other, in addition to any individual insulation coating, and areprotected from possible damage. Example polymers include thermosetelastomers, such as silicone, thermoform polymers, such as polyurethane,and thermoform elastomers, such as Santoprene®, to name a few.

As shown, the transgastric probe 2000 has an elongate cylindricalportion 2016 which joins with a hub 2018 which in turn joins with thelead body 2014. Typically, the cylindrical portion 2016 has a length inthe range of approximately 15 mm to 35 mm and a diameter in the range ofapproximately 2 mm to 5 mm, with a preferred diameter of 3 mm, but notso limited. Such dimensions are chosen to allow sufficient extension ofthe cylindrical portion 2016 through the gastric pouch wall and into thegastric pouch. In addition, the cylindrical portion 2016 has anatraumatic tip, such as having a smooth, rounded shape, to reduce anypossibility of acute or chronic injury to the lining of the gastricpouch.

In this embodiment, the cylindrical portion 2016 includes a tissueengagement feature 2012. The feature 2012 extends radially outwardly andis positioned a distance from the hub 2018 to assist in maintaining atleast a portion of the stomach wall 2007 therebetween. The hub 2018 mayhave a variety of shapes and may be configured to maintain thecylindrical portion 2016 at an angle theta in relation to the lead body.Alternatively or additionally, in this embodiment the cylindricalportion 2016 is disposed at a 110 degree angle in relation to the leadbody. It may be appreciated that the angle theta may range from 0 to 180degrees, or 90 to 180 degrees, however an angle of less than 180 degreesis typically desired to assist in extending the lead body 2014 acrossthe outer surface of the stomach.

The cylindrical portion 2016 has a hollow construction within which isdisposed a sensor 114. It may be appreciated that a plurality of sensorsmay also be used. In this example, the sensor 114 comprises athermistor. A variety of temperature sensors can be used, includingnegative temperature coefficient thermistors, positive temperaturecoefficient thermistors and thermocouples and thermopiles. In thisexample, a set of conductive wires 2002 a and 2002 b extends from thesensor 114, through the hub 2018 and through the lead body to theproximal end of the lead. The hollow section of the cylindrical portion2016 is filled with potting material, such as epoxy, to protect and sealthe sensor 114 and conductive wires 2002 a and 2002 b in place. Togetherwith the epoxy, the cylindrical portion 2016 and hub 2018 create acontinuous barrier to protect the thermistor from fluid or otherenvironmental factors. Since in this embodiment the probe 2000 is formedfrom a thin thermally conductive metal, external surface temperaturechanges are quickly thermally-conducted to the internal thermistor formeasurement. Further, the electrically conductive metal allows the probe2000 to act as a return electrode. Thus, another conductive wire 2006 aextends from the probe 2000 through the lead body and attaches to theconductive metal to act as a return electrode.

FIG. 2G1 shows an alternative embodiment of the multifunctionaltransgastric probe. The multifunctional transgastric probe may beconstructed from concentric cylinders of alternating conducting(metallic) and insulating (e.g., plastic, ceramic) stomach-acidresistant materials. In this embodiment only two materials need beexposed to the internal stomach environment. Advantageously, theconcentric design permits relatively large areas of contact betweencylinders to facilitate sealing. Sealing can be accomplished withadhesive and/or thermal expansion/contraction. All electricalconnections are made internal to the electrode assembly and can bereadily accessed during assembly. The impedance electrode can share anelectrical wire with the temperature sensor/thermistor, reducingwire-count if desired. Weak impedance-measurement excitation currentlargely follows electric field lines. Desirably an insulating cap 2009will keep the opposing wall of stomach from shunting the impedancecurrent.

FIGS. 2G2 and 2G3 show further alternative embodiments of themultifunctional transgastric probe concentric cylinders of alternatingconducting (metallic) and insulating (e.g., plastic, ceramic)stomach-acid resistant materials.

FIG. 2H shows an alternative embodiment of the multifunctionaltransgastric probe which also comprises a portion of a color detector2030 at the distal end of the probe 2000. FIG. 2H1 shows a close-up viewof the multifunctional transgastric probe which comprises a portion of acolor detector 2030. The entire color detector 2030 is comprised of asource of white/visible light e,g., LED 2032 conducted into the cavityof the gastric pouch or stomach via a fiber-optic illuminating ‘lightpipe’ 2034, a transparent nosepiece 2036 attached to the distal portionof the multifunctional transgastric probe, a second ‘light pipe’ 2038which conducts a spectrum of light that has passed through materialwithin the stomach and/or been reflected from the surface of the insidewall of the stomach, and a color sensor 2040 which e.g., generateselectrical signals corresponding to the intensities of the red, green,and blue wavelengths of the reflected light. The probe 2000 includes thetransparent nosepiece 2036 and its provisions for interfacing to theilluminating and reflected light pipes. The light conducting material(light pipes) 2034 and 2038 and the transparent nosepiece are producedfrom light-conducting, optically transparent (at the wavelengths ofinterest) and corrosion resistant to the environments of the stomach andgastric pouch, such as pure silicon dioxide, quartz, or diamond. Thelight illuminates a small area of the gastric pouch wall 2042 oppositethe protruding electrode. The light also illuminates ingestedmaterial(s) 2044 located between the nosepiece and the opposite gastricpouch wall. Source light reflected by the generally opposed gastricpouch wall and/or ingested contents re-enters the nosepiece 2036 as wellas a second robust light-conducting component, and is subsequentlyconducted, via a second light pipe, to a color light sensor e.g., threephotosensors or photodiodes 2042, 2044, and 2046 with color filters, oran integrated commercial color light sensor (not shown). Each of thephotodiodes 2042, 2044, and 2046 measures its designated colorintensity, e.g., red, green, and blue. The sums and ratios of theseintensities are then used as an indicator that (a) the stomach islargely empty, or (b) there is ingested material within the stomachcavity, and (c) the composition of the ingested material (with limitedprecision).

The light path(s) may be of significant alternate forms and could beseparate from the temperature probe. The nosepiece maintains a space infront of the light-conducting components such that light is not blockedfrom reflecting from the stomach wall and/or ingested material andsubsequently being sensed. The detected wavelengths can also includethose of non-visible light e.g., infrared, desirably near infrared. Inparticular, two bands detecting ranges 1130-1180 nm and 1360-1400 nm canbe used to differentiate water from sugared beverages and beer.

FIG. 21 shows a schematic configuration of the color detector 2030 andsensor 2040 in the multifunctional transgastric probe in a case when thegastric pouch is largely empty or in the presence of a clear liquid suchas water. Note that the color intensities measured by the photodiodesreflect the color of the interior of the gastric pouch cavity.

FIG. 2J shows a schematic configuration with a sensor response in a casewhen the gastric pouch cavity includes a translucent material such ascoffee or a dark-colored soda.

FIG. 2K shows a schematic configuration with a sensor response in a caseafter ingestion of a largely opaque meal in the gastric pouch cavity.

Alternatively or additionally, a sensor 114, desirably a temperaturesensor, may be otherwise positioned elsewhere within, coupled to or incommunication with the patient. In some embodiments, data obtained fromthe sensor 114 may be pre-processed to remove noise or unwantedartifacts before it is analyzed. Additional sensors may be included,including a core body temperature sensor, an accelerometer, and/or aheart-rate/respiration-rate sensor(s) to measure patient activity or thelike. The housing of implanted device 110 will typically contain abattery and circuitry of the implanted device, and may be similar toother known implantable stimulator housing structures used for heartpacemaker systems and the like. A suitable heart rate sensor maycomprise an electrode or other sensor engaging the stomach wall so as toreceive (far field) electric signals from the heart. Optionally, such aheart rate sensor may employ the same electrode as used to stimulatestomach tissue to inhibit ingestion, though separate electrodes mayalternatively be used. Heart signals, accelerometer signals, and/orother activity sensor signals may, like temperature or other ingestionsensor signals, be processed and recorded using circuitry 116. Suitablesensors and implantable devices, as well as aspects of the other devicesof the devices of system 100, are described in (and/or may be modifiedfrom those described in) U.S. patent application Ser. No. 12/754439filed on Apr. 5, 2010, U.S. patent application Ser. No. 12/145,430,filed on Jun. 24, 2008 and U.S. patent application Ser. No. 10/950,345,filed on Sep. 23, 2004, all of which have previously been hereinincorporated by reference. Processing of sensor signals so as toidentify or classify ingestions events and/or patient activity level tobe communicated by system 100 (which may occur partially or entirely inimplanted device 110, home monitor 120, or server 130) may be more fullyunderstood with reference to Provisional U.S. Patent Application No.61/122315, filed on Dec. 12, 2008 and U.S. patent application Ser. No.12/637452, filed on Dec. 14, 2009 which were also previouslyincorporated herein by reference.

The home monitor 120 includes a processor 122, a storage medium 124, andtransmitting/receiving circuitry 126 and is capable of interrogating theimplanted system 110 (and of receiving sensor-based data in response)when the patient is within a predetermined distance of the monitor. Insome embodiments, this distance is approximately twenty to thirty feet.The data interrogation could also be initiated by the patient via aninput into home monitor 120 or a mobile device such as an iPhone® smartphone with abiliti® Pocket Coach software. The information communicatedto the home monitor 120 is encrypted and sent via the internet to aHIPPA compliant server 130. The information is then accessible directlyby the patient 140 or by approved medical personnel serving as thepatient's health coaches (optionally via a workstation 160) via a secureweb site or other portal 150. While the home monitor will often comprisea desktop computer or other desktop unit powered by a wall plug,alternative systems may employ home monitors with smaller form factors(the home monitor optionally comprising and/or being similar in size toa notebook computer, a smart phone, a personal digital assistant, or thelike) powered by batteries or other portable power sources. Wherewireless phone capability is not available to a patient (such as for apatient visiting or living in a rural area) the home monitoring systemcould also comprise a hand held computer and a port that is connected tothe internet via a land-based telecommunications link such as via amodem and telephone connection. The implanted device could beinterrogated through radiofrequency (RF) communication with the handheldcomputer. Such a handheld computer could also be used to enter journalinformation. Placing the hand-held computer in the port would allowuploading of retrieved device data, and journal entries to the internetportal. Some or all of the functionality of the home monitor 120 mayinstead be implemented using a portable device 170 such as a smartphone, personal digital assistant, or the like. Even when a home monitor120 is included in the system, such portable devices will allow thepatient to benefit from communications to and/or from server 130 whenthe patient is out of the house.

The server 130 contains a number of algorithms designed to evaluate theimplanted device data logs in comparison with goals established by thepatient and his or her health coaches 160. Based upon the results of theanalysis, such as whether the goals have been met, coaching messages maybe sent to the patient, for example via email, text message or telephonecall. The messages are designed to provide encouragement for positiveresults and positive reminders for negative or neutral results. Thiscoaching feature encourages patients to obtain energy balance in theirlives. Specific examples regarding energy expenditure include sendingencouraging messages for meeting daily or weekly activity goals orsending patient alerts if extended periods of sedentary activity haveoccurred. With regard to caloric intake, examples include communicatingfeedback to the patient as to whether eating patterns show adherence tothe eating plan or whether caloric intake is meeting daily, weekly, ormonthly goals.

Information in the data logs from the activity and consumption sensorsof the implanted device 110 will also allow cross-checking between thepatient's activity and meal diary and device-detected events. If thediaried and the detected events do not match (such as when the senseddata indicates that food was ingested but a snack or meal was not loggedin the diary, or when a meal time or food intake quantity exceeds alogged meal), then reminders may be sent to the patient to enteradditional information in the diaries, and/or to a health coach to checkin with the patient. Diary entries may be made by a patient via multipledevices (for example, using a home computer when at home, a notebookcomputer when at the office or traveling, and/or a smart phone while ata restaurant, or the like) and in a variety of different formats(including options for text diary entries, voice entries, photo entriestaken via a digital camera or telephone, and the like). Although diariesfor the purpose of calorie counting have been typically inaccurate dueto lack of patient compliance or attention, this feedback systemfacilitates improved accuracy. In addition, alerts can be set that sendperformance summary reports to the patient's health coach and/orphysician, which allows the health coach or physician to intervene whenneeded. The intervention could be in the form of extra coaching for thepatient, revising of a weight loss/exercise plan, reprogramming of theimplanted device stimulation parameters, or the like.

In embodiments of the present invention, the patient may be providedwith a hand-held or pocket device capable of receiving reminders andother notices from the server 130, or the reminders may be sent to ageneral purpose hand-held or pocket device such as a cell phone ore-mailer, optionally using an appropriate local user interface or othersoftware resident on that device. A patient identification and/orpassword may optionally be entered to the portable device to obtainpatient data so as to prevent others from accessing sensor-based data.The notices transmitted to the portable device may include dailyinspirational messages; diet and exercise education information; andparticularly feedback messages (for example, identifying positive andnegative events, reached daily goals, missed goals, skipped meals,excessive meal quantities or times, and/or added meals or snacks). Thefeedback messages may be generated by algorithms contained on the server130; and/or cross-checking between device data logs and patientreporting. In some embodiments of the invention, patients may be offeredthe option to join an online support group of patients with similar bodymass indexes (BMI) who have similar attributes and weight loss goals.This group may meet online using the website 150 to provide support forone another, as well as review each other's results and provide supportand encouragement to each other via email or text messaging via theirpatient-associated portable devices. Hence, the patients may optionallyshare access to their sensor-based data with one or more otherappropriate patients so as to allow the other patients to act as healthcoaches to the patient in which device 110 was implanted, and/or so asto allow the implant patient to coach those other patients based ontheir associated sensor-based data. The patient will also optionallyhave the ability to invite health coaches into the online community,with the patient typically granting and managing a support group of thepatient by granting permission to individuals to whom the patient iswilling to allow access to the patient's sensor-based data. Thesupporter or member of the group may be a spouse, a gym coach, a parent,a friend, or a family member. In some embodiments, the group may includeanother patient having an implant providing sensor-based data. Hence,the group may comprise a mutual support group.

The patient and/or health coach may obtain updates by accessing a website or other portal 150. The portal will optionally comprise a securewebsite into which the patient or other system user enters a patientidentifier and/or password, allowing patients to log into the site withconfidence that the system is safe and secure. Patients should feelsensitive medical data is sufficiently protected and that highlysensitive medical data is not displayed as appropriate given the valueof the portal. Portal 150 may optionally comprise a “support dashboard,”includes a comprehensive set of weight loss tools designed to supportthe individual. In addition, the support dashboard may allow access tothe data logged by the implanted device 110 by the patient. Theusefulness of the weight loss tools included in portal 150 may beenhanced through the ease by which the patient is provided accurateinformation on his or her daily activity and consumption. Thesensor-based information may optionally be enhanced by patient reportingof specific food quantities, food types, caloric intake, and/or thelike. The support dashboard may include features such as: a caloriedatabase, an online calorie counter, a packaged food database, mealpreparation support (such as custom meal menus generated for thatpatient), an activity diary, an exercise guide and planner, a weighttracking log, a body-mass index calculator, activity or exercisereports, meal frequency and duration reports, and/or a message center.Portal 150 may present patient performance based on predeterminedactivity and caloric goals, optionally including daily kilocalories tobe burned, daily calories consumed, and/or a net summary of thepatient's energy balance. Portal 150 may also present additionalsensor-based data, including sleep or rest data (such as the number ofhours slept, a quantified quality of sleep or other rest periods, andthe like).

Referring still to FIG. 1, portal 150 may have a food calculator to lookup calories of food types, to input quantities of their planned orconsumed meals, and the like. Food calories can be input and/ordetermined in a variety of different ways, with the site optionallyemploying a food calculator or linking to a commercial calorieidentifying website such as CalorieKing.com or the like. Meal loggingmay optionally include uploading data or photos to the portal directlyor by linking to a meal logging web-base service such as that which wasoffered commercially by myfoodphone.com. Portal 150 may also havecommercially available look-up caloric and/or nutritional data from foodsuppliers, including commercial prepackaged customized foods suppliers,restaurant chains, or the like.

Portal 150 may facilitate networking with identified friends using knownsocial networking capabilities, giving users the ability to email tofriends and health care providers and accepting input from suchindividuals so as to allow them to make public or private comments andthe like. The members may connect into a live chat room sponsored by thehealth care practitioner support group (if desired). This may allow realtime coaching based on individual own performance on eating, exerciseand lifestyle opportunities. The portal may also support a group orcircle of friends to allow individuals to in chat real time or transmitmessages to one another. Portal 150 may optionally accept predeterminedor customized user data, allowing the user to store desired healthrelated information on their personal page, and to control the access ofothers to that information. This data could include blood pressure,glucose, sleep length and quality, heart rate data, and other dataindicative of the general health status or goals of the patient. Theportal will allow for daily notes from the individual, this will allowusers to note overall feelings of wellness or questions they might haveabout eating and motivations.

To enhance the efficacy of coaching and overall feedback, portal 150 mayallow for feedback from the network based on the individual's goals. Thesite will allow for messaging to the individuals own page (as well asother portable or connected device, as described above) which the userchooses. This messaging may be configured to prompt the individual basedon performance achieved or notes about missed activity events, mealevents, etc. The portal may also notify users when a member of theirselected member friends has achieved their personal goals and/oraccomplishments. Portal 150 may also include goal-setting andbehavior/goal comparison tools. Simple goal setting fields mayoptionally be available for the patient, though more sophisticatedsystems may allow the patient to enter a long-term goal and mayinteractively help the patient to determine short term and long termintermediary goals so as to reach their ultimate weight reductiontarget. The system may, for example, provide an indication of thequantity of exercise that would be appropriate to achieve an interim orshort term weight loss given the patient's sensed ingestion behavior.Alternatively, a reduction in ingestion may be determined based onmaintaining the patient's sensed activity level may be identified by thesystem. Expected results from changes in ingestion and activity may beidentified by the system. As significant weight loss may not be measureduntil a patient has maintained compliance for a relatively extendedperiod, more immediate short-term goals may also be identified by thesystem, including reduction in a size of the patient (such as areduction in dress or pants size, a reduction in waist size, a reductionin neck, arm, or leg circumference, an increase in walking endurance orspeed (or other quantifiable exercise parameters), or the like may alsobe identified). Portal 150 may allow the patient to revise the shortterm and long term goals throughout the course of treatment, and maygenerate comparisons between the patients measured and sensedperformance with their goals. The system may also be capable of trackingperformance against team goals, with a team comprising weight-losspatients of a group. Team goals may be generated by the team, ahealthcare provider of the team, or both. As an example, a physiciancould create a team of patients, each patient of the team having animplanted device. The physician could then work with the team to set ateam's goals. This will allow the spirit of competition to be added intothe mix for changing the behavior of the individual members of the team.

Portal 150 may include or be linked to one or more reference websites.The portal will preferably have a number of selected reference sites formembers to choose from. These sites will allow users to select from anumber of tools which the users may prioritize or the site may keep acurrent list of most frequently used sites. This allows users to referto a particular reference site based on changing priorities andbehaviors. Suitable reference sites may include information on nutrition(food selection and net calorie), food preparation, activity guidelines(walking and other exercises), Kcal Expenditure charts (includingactivities of daily living), and/or the like. Portal 150 will allow theuser to communicate their health status to others, such as by providingthe ability to send permission to view the patient's page to an MD,nutritionists, or a selected friend or group member. The patient's pageon the portal will typically store a history of the patient, includingtheir weight, wireless or other uploads by or regarding the patient, andthe like. Educational links may facilitate access to nutritionalinformation, exercise information, stress management techniques, andlifestyle coaching guides.

As indicated above, a number of additional devices may communicate withthe components of system 100 shown in FIG. 1. Along with portable orhandheld devices 170 (such as a BlackBerry™ wireless e-mailer, an iPod™or other mobile music player, an iPhone™ or other mobile phone, and thelike), home monitor 120 or server 130 may communicate with scales (formeasuring a weight of the patient or food), pedometers, and the like. Inexemplary embodiments, home monitor 120 receives wireless telemetry froma scale, glucose monitor, blood pressure cuff, and/or the like.

FIG. 1A shows an exemplary gastric band sensor system implant 900. Thisembodiment includes a gastric band, laparoscopically implanted, alsoknown as a lap band 902 having a fluid-filled cuff 903 coupled to animplanted port 904 via a fluid conduit 906. The gastric band maycomprise any such lap band currently marketed or available in clinicaltrials, as for example, the Realize® Adjustable Gastric Band fromEthicon Endo-Surgery, Inc., the Lap-Band® from Allergan, Inc., theMidband™ from Medical Innovation Developpment, and Heliogast® Band fromHelioscopie, MiniMizer Extra from Bariatric Solutions. Thegastrointestinal constriction provided by lap band 902 can be varied byinjecting or removing fluid from port 904 using a syringe. Along withmechanically constricting gastrointestinal flow, system 900 includes ahousing 920 with circuitry comprising a processor 922 and a battery 924to wirelessly transmit signals generated in response to signals from oneor more sensors 928 to a data collection center. The data collectioncenter comprises the web portal 150 shown in FIG. 1 or a data server.Note that the housing 920 may optionally be incorporated into port 904.

System 900 will sense ingestion using signals from at least one sensor926. Sensor 926 comprises at least one of a pressure 928 (e.g. aMEMS-type, strain-gage, etc.), temperature, pH, acoustic, or opticalsensor to detect food or drink intake. Sensor 926 may also comprise anactivity sensor, such as an accelerometer, heart rate sensor,temperature-based ingestion sensor and/or a core body temperaturesensor. The at least one sensor could be placed at various locations,for example at the port 904, at the lap band 902, etc. The at least onesensor may be wired to the housing 920, or communicate wirelessly withthe processor in the housing.

FIG. 1B illustrates the electrical stimulation component of the gastricband sensor system implant 900. The stimulator 20 comprises a housing 21implanted subcutaneously within a patient. The stimulator furthercomprises leads 22 a, 23 a extending from the housing 21 through theabdomen and to the stomach 100 where electrodes 22, 23 at the end of theleads 22 a, 23 a are implanted into the stomach muscle layer from theoutside of the stomach 100. A method of implanting the stimulatorhousing 21 and laparoscopically implanting the electrodes 22, 23 in thestomach 100 is generally known to those of ordinary skill in the art.

The housing 21 further comprises a sensor 24 a located on the housing 21and/or a sensor 24 b located elsewhere in the patient and coupled to theelectronic circuitry 29, (FIG. 1B) in the housing 21 by lead 24 c. Thesensor 24 a or 24 b may, for example, include an accelerometer that isconfigured to sense motion of the patient. The stimulator also includessensors 25, 26, that are implanted on and in the stomach 100,respectively, with leads 25 a, 26 a extending from the sensors 25, 26 tothe housing 21. Sensor 26 is exposed to the inside of the stomach 100while sensor 25 is attached to the outside of the stomach. Leads 22 a,23 a and 24 c, 25 a, 26 a are electrically coupled to the electroniccircuitry 29 located in the housing 21. When the sensors 25, 26 areimplanted in the stomach, they may sense presence of material in thestomach, composition of such material and temperature, pH or pressurewithin the stomach, and/or patient motion corresponding to respirationor gross movement. Sensors positioned on the stomach may also sensevarious parameters that indicate the actions of the stomach, e.g.,movement, contractions. The sensors positioned on the stomach may alsoutilize various imaging techniques, e.g., ultrasound, and light, toidentify presence or composition of food or material in the stomach.

In use, once the stimulator 20 is deployed, electrical stimulation isprovided through electronic circuitry 29. The electronic circuitry 29 iscapable of producing various types of programmable waveforms thatprovide stimulation to the smooth muscle lining of the intestinal tract.It is well known to those of ordinary skill in the art, there are manydifferent types of electrical stimulation programs and strategies whichcan be utilized for providing electrical stimulation parameters throughthe circuitry 29, the principal focus being providing electricallystimulating parameters for the stomach. In one embodiment the focus ofthe electrical stimulation is to cause gastric retention of food toproduce a sensation of satiety. Another focus of the electricalstimulation may be to interfere with the innate peristalsis of thestomach, which is intended herein to mean to movement of the stomachthat typically also acts to break down food and/or moves materialtowards the antrum or out of the stomach. Another focus is to cause asensation of satiety by stimulating the stomach, neural tissue of theenteric nervous system and vagal afferent pathway. Another focus is tocontrol the secretions relating to the stomach or hunger by stimulatingthe stomach.

An embodiment of the electronic circuitry 29 is illustrated in FIG. 1C.The electronic circuitry 29 of the stimulator is located in the housing21. The electronic circuitry 29 may be in a form of a standardized chipthat may be used with one or a variety of sensors, including but notlimited to those described herein. The electronic circuitry 29 orsimilar electronic circuitry may also be included with separatelyimplanted sensors or components of the system. Thus the variouscomponents may be configured to communicate with the other componentsthrough telemetry or similar signaling.

The circuitry 29 comprises, a microprocessor or controller 40 forcontrolling the operations of the electronic circuitry 29, an internalclock 41, and battery device 44 such as a pair of lithium iodinebatteries for powering the various components of the circuit 29. Assuch, the controller 40 and battery device 44 are coupled to each of themajor components of the circuit as would be apparent to one of ordinaryskill in the art. The battery 44 has its output supplied to a DC-to-DCconverter 44 a to provide a higher voltage, which is utilized forelectrical stimulation pulses. The DC-to-DC converter 44 a isconventional and provides an output voltage desired for stimulation. Theinternal clock 41 may also include a real time clock component thatcommunicates with the controller/microprocessor 40. The real time clockcomponent may be used to control stimulation, e.g. by stimulating orallowing stimulation only at a particular time of the day. The real timeclock component may also provide a date/time stamp for detected eventsthat are stored as information in a memory device. The memory may bepreserved by only saving information corresponding to an event ofinterest which is saved along with the time/date when the eventoccurred.

The controller 40 is coupled to stimulation driver 42, which is coupledto stimulating electrodes (e.g., 22, 23) that are used to provideelectrical stimulation in accordance with programmed parameters,including in response to sensing conditions relating to the patient orthe patient's intake of food as described herein.

The controller 40 is coupled to ROM 43, which contains the programinstructions for the controller 40 and any other permanently storedinformation that allows the microprocessor/controller 40 to operate. Thecontroller 40 addresses memory in ROM 43 through address bus 43 a andthe ROM 43 provides the stored program instruction to the controller 40via data bus 43 b. The controller/processor 40 controls the telemetrycoil 45, which communicates with an external control or programmingdevice 60 (FIG. 1D), e.g., via a modulated RF signal.Controller/processor 40 is coupled to a buffered oscillator 51 thatprovides an RF signal to be emitted from the telemetry coil 45. The RFsignal is preferably at about 100kHz-5 Mhz so that the signal isefficiently transmitted through tissue. The controller 40 controls theoscillator 51 and provides data to be modulated with the RF signal. Forexample, various sensed data such as motion, transmitted or reflectedlight parameters, pressure, pH, temperature, local muscle contraction,strain, impedance, electrical activity (EMG) etc., may be delivered viaa modulated signal through the telemetry coil 45. When the telemetrycoil 45 is receiving an external telemetry signal, the bufferedoscillator 51 is disabled. Telemetry signals received on the telemetrycoil 45 are detected in a detector circuit 51 a and communicated tocontroller 40. The detector circuit may be selected based on themodulation used for the telemetry signals.

The circuit 29 may also be coupled through A/D converters (withamplifiers) 46 a, 46 b, 46 c, 46 d to one or more sensors 25, 26, 24 a,24 respectively. The A/D converters convert a representative analogelectrical signal from the sensors into a digital signal communicated tothe controller 40. Suitable types of these sensors may include but arenot limited to the types of sensor described herein. Such sensors atvarious locations are coupled to the electronic circuit by way of leadwires or through alternative means of communication such as telemetry,wireless communication or indirectly through a separate controller e.g.,controller 70 shown in FIG. 1D.

Controller 40 is coupled to RAM 50 via an address bus 50 a foraddressing a location in RAM 50 and a bi-directional data bus 50 b fordelivering information to and from RAM memory 50. The RAM memory 50includes event memory 48 that temporarily stores data recorded bysensors 24 a, 24, 25, 26, or electrodes 22 23. RAM memory 50 alsoincludes a programmable memory 49 which may be programmed, for example,by an external programmer 60. The data stored in the programmable memorymay include specifications for the electrical stimulation operatingmodes (e.g., waveform, type of stimulations: for pacing, inducing,interfering with or reversing contraction, for interfering with innateactivity, for controlling biochemistry or secretions relating to thestomach, or other types of stimulation, such as neural stimulation) andvarious procedures or responsive parameters (e.g., for turning on or offvarious sensing or stimulation functions, parameter modification,protocols or procedures for recognizing various conditions of thepatient of the patient's gastrointestinal tract and protocols orprocedures for responding to such recognition). These data andprocedure/protocol elements, including responsive elements that respondto sensed data, may also be located in whole or in part in othercontroller devices that may be located independently from electroniccircuitry 29. The programming may be done in response to sensedinformation or, it may be done automatically by an external controlleror as desired by a treating physician, etc. Sensed data acquired fromthe sensors or electrodes, provided to the controller 40 may be storedin event memory 48 in the RAM 50. The data stored in the event memory 48may be sent intermittently as data bursts via the telemetry coil 45, asopposed to continuously, in order to save battery power. The clock mayalso mark or date/time stamp the data stored in event memory. Theprocessor also may select events based on predetermined thresholds orcharacteristics that are to be stored as a significant event, whileother events are filtered out and not stored.

The electrodes 22, 23 are coupled through A/D converters 46e and 46f tothe microprocessor 40. A/D converter 46e converts the electrical EMGsignal sensed by the electrodes 22, 23 into a digital signalrepresentative of the EMG electrical activity, which is delivered to themicroprocessor/controller 40 and stored in the event memory 48 in theRAM 50. Also, the A/D converter 46f converts the electrical signalsensed by the electrodes 22, 23 and provided through the impedancecircuit 53 described below, into a digital signal representative oftissue impedance, which is delivered to the microprocessor and stored inthe event memory 48 in the RAM 50.

The electrode 22, 23 outputs are used to provide electrical stimulationdelivered through the stimulation driver 42 to electrodes. Thestimulation modes and parameters can either be set using the externalprogrammer 60, or they may be set in response to sensory feedback. Thesame electrode outputs may be used to sense impedance of the stomachtissue or of the contents of the stomach depending upon the location ofthe electrodes. Impedance circuit 53 is used to sense impedance and EMGor other electrical activity information is provided to the processor 40through A/D converter 46 e. The electrodes 22, 23 are coupled throughcoupling capacitors 55 a and 55 b respectively, to output of electricalstimulation driver 42 and input of A/D converters 46 e, 46 f.

The impedance circuit 53 comprises a constant current source oscillator54 that oscillates at a frequency of 50-100 kHz, and A/D converter 46fwith an output coupled to the controller 40. The oscillator 54 providesa constant current source through electrodes 22, 23 resulting in avoltage across the electrodes 22, 23 that is representative ofimpedance, in view of the constant current. The voltage is providedthrough and is converted by A/D converter 46f to a digital signalrepresentative of impedance. A/D converter 46f has a bandwidth thatincludes the 50 kHz frequency signal while filtering out the electricalstimulation signal that is delivered to the electrodes 22, 23 throughelectrical stimulation driver 42, and the EMG signal that is sensed bythe electrodes 22, 23. Both of the outputs are filtered out by A/Dconverter 46 f. A/D converter 46e has a bandwidth that filters out the50-100 kHz signal. Further, when a stimulation signal is beingdelivered, the controller 40 does not receive signals from A/Dconverters 46e and 46f Thus the EMG and impedance sensing functions andthe stimulation deliver functions may be separated through theelectronic circuitry 29, though using the same electrodes.

An additional circuit 58 may be provided in the electronic circuitry 29comprised of similar components configured like impedance circuit 53.The circuit 58 delivers an interrogating electrical pulse to theelectrodes 16, 17 and senses impedance of material between theelectrodes. The electrodes 16, 17 are positioned to be in electricalcontact with contents of materials that may be in the stomach

Additional stimulating sensing electrodes and corresponding signalprocessing circuits may also be provided.

FIG. 1C illustrates the electronic circuitry 63 for external programmer60. The electronic circuitry 63 comprises: a microprocessor orcontroller 70 for controlling the operations of the electroniccircuitry, an internal clock 71, and a power source 74 such as batterydevice for powering the various components of the circuit 63. As such,the controller 70 and battery device 74 are coupled to each of the majorcomponents of the circuit as would be apparent to one of ordinary skillin the art. The controller 70 is coupled to a speaker 67 that providesaudible alerts and a display 66 such as a CRT to display data such asrecorded data, sensed parameters, treatment parameters and status ofdevice (e.g. position or battery charge status). The controller 70 iscoupled through a buffer 64 to external input device 65 that is used toprovide program parameter input, e.g. from a user, for a user to requestdata displayed in a desired format through display 66 or speaker 67, orto turn device on and off. The external programmer 60 is also providedwith an external data port 68 to interface with a computer and provide ameans for bi-directional communication of data or commands. The computermay provide programming or data to the controller/microprocessor 70. Auser may also interface with the computer to provide treatment protocolsor changes in protocols, etc. Also, a user may control the turning onand off of the stimulation program.

The controller 70 is coupled to ROM 73, which contains the programinstructions for the controller 70 and any other permanently storedinformation that allows the microprocessor/controller to operate. Thecontroller 70 addresses memory in ROM 73 through address bus 73 a andthe ROM 73 provides the stored program instruction to the controller 70via data bus 73 b.

The transceiver comprises a telemetry coil 74, an oscillator 72 and anA/D converter 76. The controller 70 controls the telemetry coil 75,which communicates with stimulator electronics 29 (FIG. 1B) through itstelemetry coil 45. Controller 70 is coupled to an oscillator 72 thatprovides an RF signal, preferably having a characteristic frequencyof500 kHz or higher, to be emitted from the telemetry coil 75. Thecontroller 70 controls the oscillator 72 and provides data to bemodulated with the RF signal, for example, programming information,stimulation parameters, etc. The telemetry coil 75 also receivesinformation transmitted via RF signal from telemetry coil 45 on thestimulator 10 such as various sensed data, e.g., temperature, pressure,pH, impedance of the stomach or of its contents, optical characteristicsof stomach contents, motion data, electrical activity (EMG), etc. Thereceived RF signal is passed through A/D converter 76 and is transmittedto the controller 70.

The data is delivered to the event memory 78 in RAM 77 by way of databus 77 b for temporary storage. The data may be retrieved from RAM 77 byaddressing the storage location via the address bus 77 a.

Event memory 78 temporarily stores data sensed by sensors 24 a, 24 b,25, 26, or electrodes 22, 23; recorded through controller 40; anddelivered via telemetry to the external programmer 60. The data may thenbe downloaded onto a computer using the external data port 68. The RAM77 also includes a programmable memory 79 which may be programmed, forexample, to specify operating modes such as waveform, frequency, pulsewidth, amplitude, repetition rate, etc. which programming is thentelemetrically communicated to the stimulation device 20. The modes andparameters can either be set using an external programmer 60 and/or setin response to sensory feedback according to programs.

The stimulator 20 may be programmed to deliver electrical stimulation inresponse to sensed parameters. The sensors 24 a, 24 b, 25, 26, orelectrodes 22, 23, depending upon their specific location, may comprise(but are not limited to): a temperature sensor that may sense a changein temperature or a rate of change in temperature that indicatesingestion of food or liquid; a pH sensor that may be used to determinewhen food has been ingested; an optical emitter/sensor that may be usedto determine the presence and/or composition of food; a pressure sensorthat may be used to sense motility patterns, e.g. presence, strength orfrequency of contractions and presence of food or drink bolus at thelocation of or passing through the band; a contractions sensor that mayprovide information on stomach contractions and local responses tostimulation; an impedance sensor that may provide information on thecontent of the stomach and amount of stretch of the stomach wall and/oran electric sensor that may determine when a characteristic EMG patternthat represents meal stages, nausea and autonomic nervous system status;a motion sensor that determines an activity level or wakefulness of asubject; a biochemical sensor that provide information on biochemicalcompositions relating to the stomach such as secretions.

The responsive devices may comprise at least one sensor and at least oneresponsive element. From sensed information, the responsive elementdetermines the existence of a condition, e.g., presence of food;ingestion of food; type of food ingested; activity level of a subject;wakefulness of a subject; time of a daily cycle or schedule;contractions of the stomach, stress level, nausea, etc.

The responsive element may combine a number of sensed parameters todetermine the existence of a condition or circumstance or a probabilityof the existence of a condition or circumstance. The responsive elementmay thereupon determine a course of treatment, including protocols,stimulation parameters and whether or not to stimulate. In one variationresponsive element may respond by stimulating to interfere with thestomach contractions; to slow, stop or reverse the innate peristalticcontractions that tend to move food through the stomach.

For example, the combined determination of temperature changesindicating likelihood of food ingestion, and an accelerometer indicatingthat a subject is not sleeping or is not highly active may trigger aresponsive element to stimulate the stomach to retain food for apredetermined period of time. The accelerometer can determine a lowlevel of activity indicating likelihood of a sleep state, but may beoverridden by a temperature sensor sensing that food has been ingestedand thus requiring stimulation. PH may be used in a similar manner astemperature to indicate a likelihood of food ingestion. A timer may alsoconfirm the likelihood that food is being eaten given the time of day,or may refrain from stimulating in spite of food being ingested if it isa certain time of day, e.g., when the stomach is naturally cleaning outas it typically does during the night.

The responsive element may receive input from one or more sensors and,in response, the responsive element may interrogate another sensor forinformation to determine a course of action. This may be used to savebattery or power consumption. This may also be used to confirm theexistence of a condition or circumstance using more than one sensor. Forexample, one or more sensors may provide information that food has beeningested. Upon making this determination, another sensor may betriggered to determine what type of food has been ingested. For example,an impedance sensor may determine characteristics of the content of thestomach by measuring the impedance of the contents of the stomach. Anoptical emitter/sensor may sense the light reflectance/transmissioncharacteristics of contents of the stomach. This information may berecorded in a memory device and downloaded. Also the information mayelicit a simulation response controlled by the responsive element when acertain type of food is detected. In addition foods may be provided aspart of an eating regimen that have markers for different types of food.Gastric retention of some foods may be created while permitting movementof others out of the stomach.

As shown in FIG. 1A, the sensor 928, desirably a pressure sensor, may bemounted in fluid communication with port 904. FIGS. 2A-2C illustratealternative embodiments of system 900. FIG. 2A shows sensor 928 coupledto the fluid-filled cuff 903, the housing 920, circuitry 922, andbattery 924 are also attached to the lap band 902. FIG. 2B shows sensor928 coupled to the fluid filled cuff 903, while housing 920, circuitry922 and battery 924 are located outside the lap band 902, optionallyattached to the implanted port 904.

FIG. 2C shows an embodiment of system 900 comprising at least twosensors 926. Pressure sensor 928 may be coupled to the fluid-filled cuff903. The second sensor 926 may comprise a temperature sensor 927penetrating the stomach wall, coupled to the housing 920 or to the fluidfilled cuff 903 and pressure sensor 928 (not shown). This embodiment isparticularly suitable when the sensor 928 must collect data from insidethe stomach. In an alternative embodiment the second sensor 926 maycomprise a sensor attached to the outside of the stomach 925, coupled tothe housing 920 or to the fluid filled cuff 903 and pressure sensor 928(not shown). In yet another alternative embodiment, system 900 comprisesa combination of at least three sensors 928, 927, and 925, as describedabove.

FIG. 2D shows an embodiment of system 900 comprising two pressuresensors 928 coupled to the fluid-filled cuff 903. One pressure sensor928 may located above the fluid filled cuff, to measure the pressureabove the lap band, and the other may be located below the lap band tomeasure the pressure in the stomach, below the level of the lap band.

FIG. 2E shows an alternative embodiment of system 900 comprising atleast two lap bands, each lap band comprising at least one sensor 926.The lap bands may comprise different elasticities and each lap band'selasticity may be changed dynamically. The superiorly-located lap bandmay be used to reduce food intake and sense ingestion events with the atleast one sensor. The inferiorly-placed lap band may be used primarilyfor sensing purposes with the at least one sensor. Since theinferiorly-placed lap band may not be inflated, it may need to be fixedin its desired location with seromuscular sutures such as the MiniMizerExtra from Bariatric Solutions, or other means known in the art. If thesuperiorly-placed band is not fully inflated, it may also need to befixated using seromuscular sutures, or other means known in the art. Thedual lap band set-up may also comprise other sensors, such as forexample a combination of optical sensors that can measure ingestionvelocities in the lower esophagus and upper portion of the stomach.

FIG. 2F shows an alternative embodiment of system 900 comprising asensor support extending through a wall of the gastric pouch 910 so asto support a sensor within the pouch and a lap band 902 comprising atleast two electrodes exposed radially inwardly of the lap band toprovide electrical stimulation to the portion of the stomach in contactwith and/or constrained by the lap band. Through the electrodes 907placed inside the lap band, the implanted device may be capable ofelectrical stimulation for therapy delivery to an appropriate portion ofthe stomach wall. For example, electrodes may be placed inside thetissue-supporting structure of the lap band, to provide electricalstimulation to the portion of the stomach in contact with the lap band.Alternatively or additionally, electrodes may also be placed on themultifunctional transgastric probe 2000, suture tabs of the lead body(not shown), or active can/stimulator housing (not shown). Theelectrodes can be intramuscular or surface, uni-polar or bi-polar, andwith or without high surface area coating. The gastric electricstimulation functions and sensing functions of the embodiment may sharethe same lead wires 909. The gastric electric stimulation and sensingelectrode configuration can be determined by the patient's visceralresponse and/or therapy results. Electrode configuration includes thenumber of selected electrodes and their respective implant locations,stimulation vectors and sensing vectors. Gastric impedance and/or itsderivatives between the gastric band electrode 905′ and the transgastricprobe return electrode 905 on the pouch can be used to measure the stateof the gastric pouch including its relaxation or distension, thepresence or absence of gastric motility, the presence or absence ofacid, the activity state of muscle or nerve fibers. Signals from thesensors on the multifunctional transgastric probe 2000 will triggertherapy, with the therapy type dependent on the classification of theevent derived from analysis of the signals.

In another embodiment, the lap band shown in FIG. 2F may be onlypartially inflated, to minimize the side effects such as nausea andvomiting; the partial inflation of the lap band will physically restrictthe food intake to a certain extent, while the electrical stimulation tofurther curb the patient's appetite. A patient will be able to achievesubstantial weight loss with minimal side effects.

Food and Drink Intake Detection

FIG. 3 illustrates ingestion of food or drink into a stomach. As foodintake occurs pressure increases within the lap band, in the upperportion of the stomach and in the lower esophagus. The lower esophagusand upper portion or the stomach will expand to accommodate the incomingfood as shown by dashed lines in FIG. 3. FIG. 3A shows a cross-sectionalview of the superior portion of the stomach constricted by a lap band902 with a fluid filled cuff 903. The lap band restricts the perimeterof the stomach, thus slowing down the passage of the food through thestomach. Following ingestion, food moves down the esophagus to thesuperior portion of the stomach, accumulating above the lap band placingan increasing amount of pressure on the lap band, as well as the upperportion of the stomach (gastric pouch), and lower portion of theesophagus. This accumulation of food and the accompanying increase inpressure on the lap band will occur up to a certain point, thenperistaltic action will push the food through the band, thereby causinga drop in pressure.

FIGS. 4A-4C show the pressure waveforms from pressure sensor signals onemight expect with food or drink input. FIG. 4A shows the expectedpressure waveforms from an ingestion of food 1000. With each swallow ofsolid food the pressure on the band increases (1020). As the food fillsup the gastric pouch, the lower esophagus peristaltic waves areinitiated in the esophagus and stomach to push food through the narrowopening created by the band. If the food is solid and dry, the digestionand peristaltic action on the food will not be enough to push the foodout as fast it is entering the stomach. At this point the patient willfeel severe discomfort and be forced to stop eating, or a vomitingreflex may occur, and maximum pressure is seen at the band (1000). Aftera delay, the peristaltic waves eventually empty the gastric pouch andbaseline pressure will be again detected at the band (1040).

FIG. 4B illustrates an overeating event; as food is ingested thepressure increases moderately 1060 until a plateau is reached 1070.However, when overeating occurs, the increased food intake beyond thevolume of a normal ingestion event increases the pressure at the bandand proximal portion of the stomach to a much higher level 1080. Thishigh pressure sets off the vomiting reflex 1090; after vomiting and thepressure rapidly decreases 1100 with the emptying of the proximalportion of the stomach.

FIG. 4C shows the expected pressure waveforms 1200 from a drinkingevent. Compared to the expected pressure wave forms from ingestion of asolid, upon ingestion of a drink 1210, there will be less buildup ofpressure because liquid passes through the band with little resistance.However, there will be transient pressure increases 1220 with eachswallow of liquid, as the increase in volume will temporarily expand thesmall upper portion of the stomach; the transient increase will dependon the rate of intake. Furthermore, since the liquid can exit theproximal portion of the stomach rapidly, it is unlikely that drinkintake will be so fast as to cause the pressure to increase to such anextent that a vomiting reflex would occur.

The differences in pressure waveforms between a normal eating event anda drinking event can be distinguished by the processor. Drinking eventswill look like multiple positive pressure transients with a return tobaseline pressure very quickly after each transient (nominally less than30 sec). While an intake of any significant volume of solid food (>20ml) will lead to an increase in pressure that lasts multiple minutes(5-30 min). In addition because of the pressure put on the gastric pouchand lower esophagus during the intake of solid foods, peristaltic waveswill cause large pressure transients at the band, on the order of 103 sof mm Hg. An increased pressure that lasts at least 5 minutes, but notmore than 60 minutes will very likely be interpreted as an ingestion ofa solid; whereas, an increased pressure that lasts at on the order of 10sec to 2 minutes will very likely be interpreted as an ingestion of aliquid. The determination of food versus drink can be based on maximumpressure amplitude and duration. These results of the food intakediagnostics can be provided to the patient or physician in order to showcompliance or lack of compliance with dietary instructions.

FIG. 5 shows the pressure waveforms 1300 that occur with injection offluid, e.g. saline, into the port of the lap band. The baseline pressure1210 increases as fluid is injected into the port. The increase in fluid(saline) volume expands the elastic portion of the port so that itcreates a smaller diameter for food to pass through, which leads to anincrease in pressure 1320 upon ingestion of food. The pressure changescaused by eating events with eating events 1320 or drinking events 1330will manifest themselves on top of the baseline pressure. However, thisbaseline pressure change may be transient as the volume of the lap bandmay adjust to accommodate the saline. The occurrence of pressuretransients due to peristaltic waves following drink intake, may indicatethat the band is too tight. These peristaltic waves may be detected atthe band and lead to automated adjustment of the band to reducepressure.

FIG. 6 shows pressure waveforms from peristaltic waves 1400. Slow wavesor peristaltic action in the stomach that is always present, is seen aslow amplitude pressure waves at a frequency of about 3 per minute 1410.The peristaltic contraction is seen as a reduction in pressure at base1420. After food intake occurs, the baseline pressure increases andpressure transients due to swallowing and peristaltic action are seenriding on the baseline change. As food intake continues, the pressure atthe band and gastric pouch increases and the pressure transients due toperistalsis increase in amplitude and frequency. As the bolus movesforward, the pressure decreases behind it. FIG. 6 shows the initialsmall transient pressure increases due to peristaltic activity. Theperistaltic waves that occur without the presence of food cause littleor no pressure change. However, beginning at the cephalic phase, andwhen food or liquid enters the stomach the peristaltic waves would causepressure waves of amplitude and duration that is proportional to theamplitude and duration of the peristaltic wave 1430. The peristalticactivity at the end of the meal is higher in order to push the food outof the stomach towards the small intestine, pressure undulations 1440caused by these peristaltic waves will occur as the pressure recovers tothe former baseline.

Pressure waves due to peristaltic activity need to be differentiatedfrom pressure waves due to food intake. In the case of a pressure sensoron the lap band these pressure waves can be differentiated because oftheir higher frequency and the amplitude of the pressure transients issignificantly higher than the overall increased pressure waves due tofood intake.

Optionally, temperature, optical, impedance, pH, or acoustic sensorssignals may also contribute data to be used in food and drink intakedetection. In one embodiment, temperature sensors can detect rapidchanges in homeostatic temperature within the stomach cavity. The rapidchanges in homeostatic temperature can be used to detect ingestionevents, and in particular, ingestions of liquids. In another embodiment,impedance spectrometers could determine water content, acidity or otherthrough the measure of impedance of materials; optical spectrometers maydetermine the composition of ingested matter (i.e. sugar, carbohydrate,and fat content); pH sensors may determine the ingestion of water andother food through changes in acidity from baseline, and acousticsensors may detect sound waves as each swallow occurs, and as a foodbolus passes through the lap band, etc. As shown in FIG. 2F, in yetanother embodiment gastric impedance and/or its derivatives between anelectrode on the band 905′ and the trans-gastric (probe) returnelectrode 905 on the pouch can be used to measure the state of thegastric pouch including its relaxation or distension, the presence orabsence of gastric motility, the presence or absence of acid, theactivity state of nerve fibers. This measurement can be used todetermine intake of food or drink or both.

Remote Communication:

Remote communication with the system 900 will allow the use of anautomated patient support system that would allow coaching type feedbackwith regards to their activity and food intake, U.S. Patent ApplicationSer. No. 61/166,636.

In some embodiments, an electrical conduit extends from a temperaturesensor within the stomach, through a transgastric port, and to circuitry922. This electrical conduit or lead could, but need not have anystimulating electrodes. Suitable trans-gastric temperature sensingprobes and ingestion analysis may described in (or may be modified fromthose described in) U.S. Provisional Patent Application No. 61/122,315,filed on Dec. 12, 2008, the full disclosure of which is incorporatedherein by reference, and U.S. patent application Ser. No. 12/637,452filed on Dec. 14, 2009.

Food or Drink Classification:

The pressure waveforms from food 1000 and drink ingestion 1200 canprovide input to a food and drink selection algorithm. The food or drinkclassification may be based on slope, maximum deviation from baseline,or other signal characteristics of the pressure waveform. When foodintake occurs, diagnostics are stored based on the timing and durationof the intake and magnitude of pressure change. The diagnostics may beused in monitoring patient's weight loss therapy.

As shown in FIG. 2D and 2E, pressure sensors may collect pressurereadings above and below the restriction created by the inflated lapband. The two pressure readings may be used to classify the ingestionevent: for example if the pressure reading above the restriction ishigher than the one below, the ingestion will be classified as a solid;if the pressure reading above the restriction is lower than the onebelow, the ingestion will be classified as a liquid or an attempt tocheat the lap band by blending solid food with a liquid to bypass therestriction of the lap band.

As shown in FIG. 9, signals from a combination of pressure sensor and atemperature sensor may be used to improve the accuracy of the fooddetection algorithm. A pressure wave sensed at the lap band may beclassified with the help of a temperature sensor that can measurechanges in the temperature of the contents of the gastric pouch at theabove the lap band. The meal classification is based on knowncharacteristics of the pressure waves due to food intake, liquid/drinkintake and an esophageal peristaltic wave. The pressure increase due tofood intake is higher than that for drink intake, because the food mustbreak down in order to pass through the small opening created by the lapband, and very little passes through immediately. Conversely with liquidintake, a smaller pressure increase occurs due to the immediate passageof the drink through the lap band. Peristaltic action can cause verylarge pressure waves, particularly at the end of a meal as the esophagusand stomach work to pass the solid food through the stomach to the smallintestines. The esophageal peristalsis working to push the food downthrough the stomach will be most noticeable at the lap band. Highesophageal peristalsis occurs when the gastric pouch becomes full. Oneway to differentiate these pressure waveforms due to peristalsis fromfood or drink intake is the downward slope of the pressure waveform, theother is temperature, because most new intake will cause a temperaturechange in the gastric pouch.

For example, a change in pressure, based on a predetermined thresholdabove the “noise floor”, is detected and the amplitude of the pressurechange is compared to a threshold level. If the amplitude is greaterthan the threshold level, then the temperature sensor is used todetermine if that pressure wave was due to peristaltic action, withouttemperature change, or a solid ingestion, with a temperature change. Ifthe amplitude of the pressure waveform did not meet threshold, then atemperature change indicates a small solid food, or drink intake; a fastrecovery of the pressure waveform will likely indicate a drink or otherliquefied intake, while a slow recovery would likely indicate a smallsolid food ingestion. No temperature change indicates low amplitudeperistaltic action or a small solid food ingestion, depending on therate of recovery of the pressure waveform. A very slow recovery to thebaseline will likely be due to some intake, even without an observabletemperature change, because the temperature sensor is less sensitiveonce the gastric pouch is full, and some food intake can be very closeto body temperature once it arrives in the gastric pouch.

FIG. 9A shows an algorithm for determining the type of intake ingestedduring the meal and its duration based on the multiple pressurewaveforms that occurred during that meal. The meal duration iscalculated starting at the first detected intake. A pressure waveattributed to peristaltic action returns the algorithm to the start, andwaits for another detected pressure wave. Once a detected pressure waveand accompanying temperature change indicate a food or drink intake, themeal timer is started and the algorithm waits for additional pressurewaves to be detected within a certain frame of time (i.e. 10 minutes).Additional pressure waves occurring within that time frame are assumedto be part of the same meal. A meal may consist of multiple pressurewaves indicating either food or drink, and also peristaltic action.

At the end of the meal, the algorithm then makes a best determination ofthe meal characteristics. The data obtained could indicate that it was along meal, and the amount of peristaltic action following the meal couldindicate the level of protein or fat in the meal. Strong peristalticaction at the end of the meal may indicate that the gastric pouch wasover-full. The proportion of drink versus solid intake can also bedetermined to understand if the patient's intake behavior isappropriate. The duration of the meal, and proportion of solid versusliquid may lead to a rough calorie estimation.

Ingestion Material Classification:

As shown in FIG. 10, signals from one of, some of, or all of theimpedance spectrometer, temperature sensor, distention sensor, and colordetector may be used in an algorithm to classify the ingested material.Thus the pH data provided by the impedance sensor can be used todetermine potential food materials. The data regarding temperaturechange over a certain amount of time can be used to classify theingested material as a solid or liquid. The amount of distention createdin the gastric pouch can further be used to classify the ingestedmaterial as a solid of liquid. The color detector data can be used todetermine whether there has been an ingestion event, whether theingested material is solid, and whether the ingested material is atranslucent liquid. Used in combination, the four types of data canprovide likely ingestion material candidates.

In one embodiment, the color detector data will be used to determinewhether there has been an ingestion event, whether the ingested materialis nontranslucent solid, and whether the ingested material is atranslucent liquid. The data regarding temperature change over a certainamount of time and the amount of distention created in the gastric pouchwill be used to classify the ingested material as a solid or liquid.Once the existence and the phase (solid, liquid, or a combination ofsolid and liquid) of an ingestion event have been established, the pHdata provided by the impedance sensor or optical analysis of nearintra-red bands can be used to determine potential food materials. Thepotential food materials will then be displayed as feedback to thepatient and/or the patient's physician.

Caloric Determination:

The detection of these peristaltic waves by the pressure sensor in thelap band sensor system may aid in the determination of caloric or fatcontent of a meal. Fat and protein chemodetectors in the small intestineprovide feedback information through a vagal pathway that controls theamplitude and duration of the peristaltic activity in the stomach andincreases the duration of time the food spends in the stomach. The maincontractions occur in the antral portion of the stomach, so they may bedetected easier with an intragastric balloon, but as the stomach emptiesthe strong peristaltic activity rises higher towards the body of thestomach and these changes could be sensed by a pressure sensor locatedin the lap band.

Lap Band Adjustment:

Individual ingestion events or ingestion patterns will trigger varioustherapeutic approaches. In alternative embodiments, the food and drinkintake data may be used to trigger automatic tightening of the lap bandupon detection of an ingestion event.

In other embodiments, the implanted device may be capable of electricalstimulation for therapy delivery to an appropriate portion of thestomach wall. For example, electrodes may be placed inside the lap band,to provide electrical stimulation to the portion of the stomach incontact with the lap band. In this case, the pressure waveforms willtrigger therapy, with the therapy type dependent on the classificationof event.

In another embodiment, the lap band may be only partially inflated, tominimize the side effects such as nausea and vomiting; the partialinflation of the lap band will physically restrict the food intake to acertain extent, while the electrical stimulation to further curb thepatient's appetite. A patient will be able to achieve substantial weightloss with minimal side effects.

In one embodiment the lap band sensor system is capable of automaticallyadjusting the lap band. The pressure signal could be used toautomatically determine when a band adjustment is needed. The adjustmentmay be based on the baseline pressure level, so that the band could beadjusted to stay at a target level. In a further embodiment, the lapband sensor system may comprise an algorithm to relieve pressure on thelap band for certain periods during the day, between meals and/or atnight, to avoid erosion and pressure damage to the stomach tissue underthe band. The pressure signal may be useful for detecting pre-vomitingand optimizing lap band adjustment.

Activity Sensors:

System 900 would optionally include a 3D accelerometer and/or a heartrate sensor. This sensor would provide feedback to the patients as towhether they are meeting their activity and exercise goals. Further,these sensors would provide estimates as to the number of caloriesburned in during exercise and/or total daily energy expenditure, asdisclosed in U.S. Provisional Patent Application No. 61/241,154 which ishereby incorporated by reference. The activity sensor(s) may allowtherapy adjustment, such as loosening of the gastric band and lesseningthe intensity or stopping electrical stimulation, during exercisesessions and for a period after exercising, to encourage good hydrationafter exercising and reward patients for healthy exercise. The amount ofloosening of the gastric band may be proportional to the exerciseintensity and duration.

The accelerometer data may also reduce the tightness of the lap bandwhen sleep is detected. This may reduce the side effects that have beenassociated with lap banding, such as acid reflux.

Intragastric Balloon Sensor System:

An alternative embodiment includes a intragastric balloon system 1500having sensors and telemetry circuitry suitable for implantation in thestomach cavity, endoscopically deployed stimulation systems havingsensors and telemetry circuitry suitable for implantation in the stomachcavity, and the like. The intragastric balloon may comprise any suchballoon currently marketed or available in clinical trials, as forexample, the BioEnterics® Intragastric Balloon (BIB®) System of the dualintragastric balloon developed by ReShape Medical™ Inc.

FIG. 7 shows an exemplary intragastric balloon-sensor-monitor system1500. The sensor-monitor device 1520 may be used in conjunction with anintragastric balloon 1510. In this case the sensor-monitor device 1520could be inserted within the balloon so that when the balloon is filledwith saline inside the stomach, the device would be enclosed within theballoon. The sensor-monitor device will comprise a sensor 1530; thesensor may comprise a pressure sensor that would pick up pressurechanges within the balloon.

Pressure changes that occur outside the walls of the balloon will changethe internal pressure of the balloon since the material of the balloonis compliant. In an alternative embodiment, the intragastricballoon-sensor-monitoring system 1500 comprises a monitoring deviceplaced outside the balloon, where a pressure sensor 1520 is attached tothe surface of the monitoring device.

Other sensors, such as pressure sensors (e.g. a MEMS-type, strain-gage,etc.), temperature, pH, acoustic, optical sensor to detect food or drinkintake and/or activity sensor, such as an accelerometer, heart ratesensor, and/or a core body temperature sensor. The at least one sensormay be wired to the sensor-monitor device 1520, or communicatewirelessly with the processor in the housing.

Sensors Used with Other Type of Stomach Reduction/Bypass Surgeries:

In the case of gastric bypass and stomach reduction surgeries, themonitoring device could be implanted at the time of surgery, potentiallyat one of the incisions used as a port for the laparoscopic tools.

The sensors and monitoring device may also be used in conjunction with acardiac device or insulin pump who have cardiac problems or diabetes asa co-morbidity with obesity.

Method of Treatment:

FIG. 8 shows a method of treating a patient with an unhealthy ingestionpattern 2000. A therapeutic implant comprising a gastric band sensorsystem or an intragastric balloon sensor system 2010 is implanted into apatient. The sensor(s) in the system will sense ingestion by the patientand generate signals correlating to the ingestion 2020. Ingestion deemedunhealthy will be inhibited 2030. For example, patients are givenbehavioral guidelines to maximize solid food ingestion, and not to drinkhigh calorie liquids or purees. If the device detects a high proportionof liquid intake, then actions will be taken to inhibit the next liquidintake. Another example of unhealthy ingestion would be when the patienthas consumed too many calories over a certain period of time based onfood content detection.

In some cases, as shown in FIG. 8A, a therapeutic implant comprising agastric band sensor system or an intragastric balloon sensor system 2010is implanted into a patient. The sensor(s) in the system will senseingestion by the patient and generate signals correlating to theingestion 2020. Ingestion deemed unhealthy will be inhibited 2040 byeither showing a display to a lifestyle coach and/or patient 2050, anincreased pressure within the bladder of the lap band or within theintragastric balloon 2060, or electrical stimulation of thegastrointestinal tract tissue with the implant 2070.

In some cases, as shown by FIG. 8B, a therapeutic implant comprising agastric band sensor system or an intragastric balloon sensor system 2010is implanted into a patient. The sensor(s) in the system will senseingestion by the patient 2080 and signals will be transmitted inresponse to the sensing 2090, and ingestion information will bedisplayed to the patient 2100 and/or the patient will be treated 2110.

In some cases, as shown by FIG. 8C, a therapeutic implant comprising agastric band sensor system or an intragastric balloon sensor system 2010is implanted into a patient. The sensor(s) in the system will sensephysical activity by the patient 2120 and signals will be transmitted inresponse to the sensing 2130, and physical activity information will bedisplayed to the patient 2140 and/or the patient will be treated 2150.In an alternative embodiment, the patient will receive both ingestionand activity information, in terms of energy balance; thus the patientwill be able to easily visualize whether the calorie intake has beenlarger than the calorie output, or vice versa.

In some cases, as shown in FIG. 8D, a therapeutic implant comprising agastric band sensor system or an intragastric balloon sensor system 2010is implanted into a patient. Upon identification of unhealthy ingestion2160, signals will be transmitted to the patient to stop the unhealthyingestion 2170.

FIG. 8E shows another alternative treatment method where a therapeuticimplant comprising a gastric band sensor system or an intragastricballoon sensor system 2010 is implanted into a patient. Allowedingestions are identified 2180 and the ingested material is allowed topass through the implant system 2190. Unhealthy ingestions areidentified 2200 and signals are transmitted to the implant to restrictunhealthy ingestion 2210.

While exemplary embodiments have been described in some detail forclarity of understanding and by way of example, a variety ofadaptations, modifications, and changes will be obvious to those ofskill in the art. Hence, the scope of the present invention is limitedsolely by the appended claims.

What is claimed is:
 1. A therapeutic implant system for treating anoverweight patient, the patient having a gastrointestinal tract and anunhealthy ingestion pattern, the therapeutic implant system comprising:an ingestion restricting implant body deployable along thegastrointestinal tract so as to separate the gastrointestinal tract intoa restricted portion of the gastrointestinal tract and a gastric pouchportion of the gastrointestinal tract upstream of the restrictedportion, the implant body comprising a gastric band defining a channeltherethrough, the gastrointestinal tract extendable through the channelof the implant body, wherein the gastric band comprises a fluid-filledpressure bladder disposed between the channel and a support structuresuch that changes in a fluid pressure within the fluid pressure bladdercorrespond with changes in an engagement force between thegastrointestinal tract and the gastric band; a sensor coupleable to thegastric pouch portion of the gastrointestinal pouch so that signals aregenerated in response to transient changes in the gastric pouch and thesignals indicate an ingestion event; a processor coupled to the signalgenerator and the implant body; a display coupled to the processor, thedisplay showing eating events identified in response to the signalsduring a plurality of days and configured for communicating feedback tothe patient, a peer group member, a health care professional, or alifestyle coach; an actuator coupled to the processor so as to alter thefluid pressure within the bladder in response to the ingestion event;and at least two electrodes coupled to the processor so as to stimulatetissue of the gastrointestinal tract such that, in response to thesignals, the unhealthy ingestion pattern by the patient is inhibited inuse sufficiently to modify the unhealthy ingestion pattern toward ahealthier ingestion pattern.
 2. The system of claim 1, wherein signalsare transmitted to the bladder from the processor, and wherein thealtering of the engagement force is induced by an actuator in responseto the sensor signals so that the pressure within the bladder isdecreased each day to allow healthy ingestion and increased each day toinhibit unhealthy ingestion.
 3. A system for treating an obese patient,the patient having a gastrointestinal tract, the system comprising: aningestion restricting implant body deployable along the gastrointestinaltract; at least two sensors so as to transmit signals in response toingestion into the patient in use, wherein the at least two sensorsinclude a transgastric probe having a probe body and a transgastric walltraversing portion, the at least two sensors separated along the probebody from the transgastric wall tranversing portion so as to be disposedwithin an interior of the gastrointestinal tract; and a processorcoupled to the at least two sensors, the processor, in response to thesignals, generating output comprising at least one member selected fromthe group consisting of: ingestion display signals based on ingestioninto the patient, and patient treatment signals.
 4. The system of claim3, wherein the gastrointestinal tract includes a gastric pouch and theat least two sensors are disposed within an interior of the gastricpouch.
 5. The system of claim 3, wherein the at least two sensors areselected from the group consisting of a temperature sensor, a visiblecolor sensor, a pressure sensor, a temperature sensor, an opticalsensor, an impedance sensor, a pH sensor, an acoutstic sensor, aneccelerometer, a heart-rate sensor, and/or an infrared light detector.6. The system of claim 3, further comprising at least one of: a displaycoupled to the processor, the display showing ingestion eventsidentified in response to the display signals during a plurality of daysand configured for communicating feedback to the patient or otherindividuals; an actuator coupled to the processor so as to alter theingestion restricting implant body in response to the ingestion event;and at least two electrodes coupled to the processor so as to stimulatetissue of the gastrointestinal tract in response to the ingestion event.7. The system of claim 6, wherein altering the ingestion restrictingimplant body includes increasing the restriction when the ingestionevent is sensed to be unhealthy and decreasing the restrcition when theingestion event is sensed to be health.
 8. A therapeutic implant systemfor treating a patient, the patient having a gastrointestinal tract andan unhealthy ingestion pattern, the therapeutic implant systemcomprising: an ingestion restricting implant body implantable along thegastrointestinal tract so as to separate the gastrointestinal tract intoa restricted portion of the gastrointestinal tract and a gastric pouchportion of the gastrointestinal tract upstream of the restrictedportion; at least two sensors configured to engage the gastric pouchportion, wherein the sensor is included in a transgastric probe having aprobe body and a transgastric wall traversing portion, the sensorseparated along the probe body from the wall traversing portion so as tobe disposed within an interior of the gastric pouch; and a processorcoupleable to the sensor so as to transmit signals therebetween, whereinthe signals are transmitted in correlation with transient changes in thegastric pouch potion of the gastrointestinal tract in use.
 9. The systemof claim 8, wherein two or more electrodes are coupled to the processor,the electrodes configured to deliver electrical stimulation to thegastrointestinal tract.
 10. The system of claim 9, wherein the two ormore electrodes are mounted along the body of the transgastric probe.11. The system of claim 8, wherein the at least two sensors may becoupled to the processor and configured to generate signals and theprocessor may be configured to process the signals so as to identifytransient changes in the gastric pouch of the gastrointestinal tract.12. The therapeutic implant of claim 8, wherein the implant body has afirst configuration and a second configuration, the size, compliance, orshape of the implant body in the second configuration being differentthan the size, compliance, or shape of the implant body in the firstconfiguration such that the implant body has an enhanced inhibition ofingestion in the second configuration.
 13. A method for treating anobese patient, the patient having a gastrointestinal tract, the methodcomprising: deploying at least a portion of an implant along thegastrointestinal tract, the implant having a body, at least threesensors and a processor; identifying, during a day and in response tosignals sent from the sensors to the processor, a candidatecharacterization of an ingested material; wherein the at least threesensors of the deployed implant include a transgastric probe having aprobe body and a transgastric wall traversing portion, the sensorseparated along the probe body from the wall traversing portion so as tobe disposed within an interior of the gastrointestinal tract;determining whether the ingested material constitutes an allowedingestion in response to the candidate characterization, and if so,allowing the ingested material to traverse the body of the implant alongthe gastrointestinal tract; determining whether the ingested materialconstitutes an unhealthy ingestion in response to the candidatecharacterization, and if so, transmitting signals from the processor tothe body so as to alter a shape, compliance, and/or size of the bodysuch that the body restricts the unhealthy ingestion.
 14. The method ofclaim 13, wherein the transgastric probe may include two or more membersselected from the group consisting of a temperature sensor, anelectrode, and a visible color sensor and/or an infrared light detector.15. The method of claim 13 further comprising: communicating feedback tothe patient, a peer group member, a health care professional, and/or alifestyle coach, wherein the feedback is based on the determination ofwhether the ingested material constitutes an unhealthy ingestion or anallowed ingestion.
 16. The method of claim 15, wherein communicatingfeedback provides a behavioral modification component for treating theobese patient.
 17. The method of claim 13, wherein the feedback iscommunicated securely via website, email, telephone, or text message.18. A therapeutic implant system for treating an overweight patient, thepatient having a gastrointestinal tract and an unhealthy ingestionpattern, the therapeutic implant system comprising: an ingestionrestricting implant body deployable along the gastrointestinal tract soas to separate the gastrointestinal tract into different portions;wherein the implant comprises a first gastric band and a second gastricband; the first gastric band located superior relative to the secondgastric band, each gastric band defining a channel through thegastrointestinal tract; wherein the first gastric band comprises afluid-filled pressure bladder disposed between the channel and a supportstructure such that changes in a fluid pressure within the bladdercorrespond with changes in an engagement force between thegastrointestinal tract and the first gastric band; at least two sensorscoupleable to the first and/or second gastric bands, the sensors capableof generating signals in response to transient changes in thegastrointestinal tract indicative of an ingestion event; a processorcoupled to a signal generator and the implant body; a display coupled tothe processor, the display showing ingestion events identified inresponse to the signals during a plurality of days and configured forcommunicating feedback to the patient, a peer group member, a healthcare professional. or a lifestyle coach; an actuator coupled to theprocessor so as to alter the fluid pressure within the bladder inresponse to the ingestion event; and at least two electrodes coupled tothe processor so as to stimulate tissue of the gastrointestinal tractsuch that, in response to the signals, the unhealthy ingestion patternof the patient is inhibited in use sufficiently to modify the unhealthyingestion pattern toward a healthier ingestion pattern.
 19. The systemof claim 18, wherein the first gastric band increases fluid pressure inresponse to a sensed unhealthy ingestion pattern so as to discourage theingestion event and restrict food intake.
 20. The system of claim 18,wherein stimulating the tissue of the gastrointestinal tract curbs thepatient's appetite.
 21. The system of claim 18, wherein each gastricband has different elasticities and each elacticity may be dynamicallyadjusted.
 22. The system of claim 18, wherein the first and/or secondgastric bands are secured in place with seromuscular sutures.